Basic Information
| Provider Information | |||||||||
| NPI: | 1750564076 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVANGELICAL MEDICAL SERVICES ORGANIZATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EMSO LEWISBURG LAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178379315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705224134 | ||||||||
| FaxNumber: | 5705224120 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 N 5TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178371407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705233350 | ||||||||
| FaxNumber: | 5705220404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2007 | ||||||||
| LastUpdateDate: | 04/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | AUCKER | ||||||||
| AuthorizedOfficialFirstName: | KENDRA | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5705222807 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | PA | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 2745719000 | 01 | PA | PERSONAL CHOICE | OTHER | 50062067 | 01 | PA | CAPITAL BLUE CROSS | OTHER | 19822-C3AH | 01 | PA | GEISINGER HEALTH PLAN | OTHER | CA5965 | 01 | PA | RAILROAD MEDICARE | OTHER | 50062067 | 01 | PA | KEYSTONE HEALTH PLAN | OTHER |